Straddle Fracture

A straddle fracture refers to bilateral fractures of the superior and inferior pubic rami (i.e., fractures of all four pubic rami), creating a free-floating anterior pelvic segment. [1-2] The term derives from the classic mechanism of falling astride a hard object (e.g., fence, beam, bicycle crossbar), though it also occurs in high-energy trauma such as motor vehicle collisions and falls from height. [3-4] Because the pelvis is a ring structure, an isolated anterior ring fracture almost always implies a concomitant posterior ring injury — CT studies show posterior pelvic ring lesions in up to 96.8% of patients with pubic rami fractures. [5-6]

The following figure illustrates a comminuted pubic rami fracture with symphyseal offset, demonstrating the principle that displaced anterior ring fractures should prompt evaluation for a second disruption in the posterior ring:

1. History

• Mechanism: fall astride a hard object (classic "straddle" mechanism), MVC, motorcycle collision, pedestrian struck, fall from height, or crush injury [3]
• Pain location: groin, perineum, suprapubic region, low back, or hip
• Ability to ambulate or bear weight — inability to mobilize is a key concern for occult instability [8]
• Voiding symptoms: hematuria, inability to void, blood at urethral meatus (suggests urethral or bladder injury) [9]
• Timing: acute onset with trauma vs. insidious onset (consider insufficiency fracture in elderly/osteoporotic patients) [10]
• Anticoagulant use — increases hemorrhagic risk even in "stable" fractures [11]

2. Alarm Features

• Hemodynamic instability (SBP <90, HR >120): suggests significant pelvic hemorrhage — mortality up to 32% in unstable pelvic fractures [12]
• Blood at the urethral meatus, perineal butterfly hematoma, inability to void → suspect urethral injury [9]
• Gross hematuria → suspect bladder injury [9]
• Open fracture (perineal laceration, rectal/vaginal wound) — dramatically increases mortality and infection risk [13]
• Progressive abdominal distension or peritonitis → intraperitoneal bladder rupture or associated abdominal injury
• Neurologic deficits in lower extremities → lumbosacral plexus injury
• Delayed hemodynamic deterioration in elderly patients — corona mortis artery avulsion can present 48–72 hours after seemingly benign pubic rami fractures [11]

3. Medications

• Analgesics: Acetaminophen, NSAIDs (if no contraindication), opioids for acute pain management
• VTE prophylaxis: LMWH (enoxaparin 30 mg BID or 40 mg daily) is the most commonly used agent; aspirin (81 mg BID) shown noninferior to LMWH for prevention of death from any cause in the PREVENT CLOT trial. Initiate within 24 hours if hemodynamically stable [14-16]
• Anticoagulants to review: Patients on warfarin, DOACs, or antiplatelet agents are at increased hemorrhagic risk and may need reversal
• Avoid: Foley catheter insertion if urethral injury suspected — obtain retrograde urethrogram first [9]

4. Diet

• NPO if hemodynamically unstable or surgical intervention anticipated
• Adequate calcium and vitamin D supplementation in elderly/osteoporotic patients for long-term bone health [10]
• Ensure adequate hydration and nutrition to support fracture healing
• High-fiber diet or stool softeners to prevent straining during recovery

5. Review of Systems

• GU: Hematuria, dysuria, inability to void, blood at meatus, vaginal bleeding
• GI: Rectal bleeding (5% of urethral injuries have concomitant rectal injury), abdominal pain, distension [9]
• Neurologic: Lower extremity weakness, numbness, saddle anesthesia (lumbosacral plexus or cauda equina)
• Vascular: Signs of DVT (leg swelling, calf pain) — up to 34% develop proximal DVT [15]
• MSK: Low back pain (posterior ring injury), hip pain, inability to bear weight

6. Collateral History and Family History

• Witnesses to mechanism (speed, height of fall, position of impact)
• Pre-injury ambulatory status and functional baseline (especially in elderly)
• History of osteoporosis, prior fragility fractures, pelvic irradiation, rheumatoid arthritis, chronic corticosteroid use — all predispose to insufficiency fractures of the pubic rami [10][17]
• Anticoagulant/antiplatelet medication use
• Family history of osteoporosis or bleeding disorders

7. Risk Factors

• High-energy trauma: MVC, motorcycle collision, pedestrian struck, fall from height [3]
• Low-energy/insufficiency fractures: Osteoporosis, advanced age, female sex, rheumatoid arthritis, chronic corticosteroid use, pelvic irradiation, renal failure, post-hip surgery mechanical changes [10][17]
• Stress fractures: Long-distance runners, female athletes (pubic ramus stress fractures near symphysis) [18]
• Anticoagulation therapy increases hemorrhagic complications [11]
• Male sex increases risk of associated urethral injury (urethral injury in 6.1% of males vs. 0.5% of females with pelvic fractures) [19]

8. Differential Diagnosis

• Unstable pelvic ring disruption (APC-II/III, LC-II/III, vertical shear) — must rule out with CT [3][20]
• Acetabular fracture — found in 28.8% of patients with pubic rami fractures on CT [5]
• Hip fracture (femoral neck, intertrochanteric) — overlapping presentation with groin pain and inability to ambulate [21]
• Pubic symphysis diastasis ("open book" injury)
• Sacral fracture (often occult on plain films) — present in nearly all patients with pubic rami fractures [5-6]
• Insufficiency fracture of pubic rami in elderly — may mimic traumatic fracture [10]
• Pubic ramus stress fracture in athletes [18]
• Osteitis pubis or athletic pubalgia

9. Past Medical History

• Prior pelvic fractures or pelvic surgery
• Osteoporosis, osteopenia, metabolic bone disease
• Rheumatoid arthritis, chronic steroid use [17]
• Prior pelvic irradiation [10]
• History of DVT/PE
• Anticoagulant use
• Chronic kidney disease (affects bone quality)

10. Physical Exam

• Vitals: Tachycardia and hypotension suggest hemorrhage — pelvic fractures can cause massive retroperitoneal bleeding [12]
• Inspection: Perineal ecchymosis (butterfly hematoma), scrotal/labial swelling, blood at urethral meatus, open wounds [9]
• Palpation: Tenderness over pubic symphysis, pubic rami, sacroiliac joints; avoid repeated manual pelvic compression/distraction testing — it is neither sensitive nor specific and may worsen hemorrhage [22]
• Rectal/vaginal exam: Assess for open fracture, rectal tone, high-riding prostate (low sensitivity/specificity for urethral injury) [9]
• Neurovascular: Lower extremity motor/sensory exam, pedal pulses
• Functional: Ability to bear weight — inability to mobilize suggests occult instability in 42% of geriatric patients with seemingly isolated rami fractures [8]

11. Lab Studies

• CBC: Serial hemoglobin/hematocrit to monitor for hemorrhage
• Type and screen/crossmatch: Essential in unstable fractures; activate massive transfusion protocol if hemodynamically unstable [15][23]
• Coagulation studies: PT/INR, PTT (especially if on anticoagulants)
• BMP/CMP: Renal function, electrolytes
• Lactate: Marker of tissue hypoperfusion/occult hemorrhage
• Urinalysis: Hematuria screening — present in most bladder injuries [9]
• Anti-Factor Xa levels: If on LMWH, to ensure adequate prophylactic dosing (many pelvic fracture patients are underdosed) [16]

12. Imaging

• AP pelvis radiograph: First-line screening; identifies pubic rami fractures, symphyseal diastasis, and gross displacement. However, posterior ring injuries are frequently occult on plain films [5][20-21]
• CT pelvis with contrast: Gold standard for full characterization of pelvic ring injury, detection of posterior ring fractures (sacral fractures, SI joint disruption), acetabular fractures, and active hemorrhage (contrast extravasation) [15][24]
• Retrograde urethrogram (RUG): Indicated before Foley placement if blood at meatus or suspected urethral injury [9][25]
• CT cystogram: If bladder injury suspected (gross hematuria with pelvic fracture) [9]
• MRI: Useful for detecting occult posterior ring injuries (sacral insufficiency fractures) not visible on CT, particularly in geriatric patients who fail to mobilize [8]
• Bone scintigraphy: Historically used for occult fractures; largely replaced by MRI [10]

13. Special Tests

• Young-Burgess Classification: Categorizes pelvic ring injuries by mechanism — APC (I–III), LC (I–III), vertical shear, combined mechanism. Useful for predicting instability, transfusion needs, and guiding surgical decision-making [20][26]
• Tile/AO Classification: Type A (stable), Type B (rotationally unstable), Type C (rotationally and vertically unstable) [2]
• FAST/E-FAST: Rapid bedside assessment for intraabdominal free fluid and pubic symphyseal widening [15][27]
• Stress radiographs under fluoroscopy: Can identify dynamic instability in patients with seemingly isolated rami fractures who fail to mobilize [8]
• Diagnostic peritoneal aspiration (DPA): Alternative to FAST in hemodynamically unstable patients to rule out intraabdominal hemorrhage [15]

14. ECG

• Not specific to straddle fractures, but should be obtained in:
  • Elderly patients (baseline cardiac assessment)
  • Polytrauma patients
  • Patients with hemodynamic instability to rule out cardiac causes
  • Pre-operative assessment
• Monitor for signs of right heart strain (S1Q3T3, new RBBB) if PE suspected in the setting of VTE

15. Assessment

A straddle fracture represents a bilateral anterior pelvic ring disruption that, by the ring principle, almost always involves a concomitant posterior injury. [5-6] Severity ranges widely:

• Low-energy (elderly/insufficiency): Often minimally displaced, may appear benign but carries significant morbidity — 16% 90-day mortality in geriatric patients with rami fractures and inability to mobilize. Occult posterior ring instability is present in ~42% [8]
• High-energy (trauma): Associated with life-threatening hemorrhage (mortality up to 32%), genitourinary injuries (4.5–7.7%), and polytrauma [12][19][28]
• Complications: hemorrhage, urethral/bladder injury, DVT/PE, infection (open fractures), chronic pain, sexual dysfunction, malunion/nonunion

16. Treatment Plan

Initial stabilization (ED):

• ATLS primary survey; apply pelvic binder at the level of the greater trochanters with legs internally rotated [15][22-23]
• If hemodynamically unstable: activate massive transfusion protocol (1:1:1 pRBC:FFP:platelets or whole blood), consider TXA [23]
• Establish urinary drainage — if no signs of urethral injury, place Foley; if urethral injury suspected, obtain RUG first → suprapubic catheter for complete PFUI [9][29]

Hemorrhage control (unstable patients):

• FAST/DPA to rule out intraabdominal hemorrhage [15]
• If intraabdominal hemorrhage → OR for laparotomy + consider external fixation
• If no intraabdominal source → pelvic external fixation + preperitoneal packing → angioembolization if still unstable [15]
• REBOA may be considered in extremis [12][23]

Definitive management:

• Stable fractures (APC-I, LC-I): Conservative management with weight-bearing as tolerated, pain control, early mobilization, and physical therapy [2-3]
• Unstable fractures (APC-II/III, LC-II/III, VS): Surgical fixation — anterior plating of symphysis for diastasis >2.5 cm; retrograde transpubic screws or anterior plating for straddle fractures; posterior fixation as indicated [1][3]
• VTE prophylaxis: Initiate LMWH or aspirin as soon as hemodynamically stable, ideally within 24 hours [14-16]

17. Disposition

• Admit (ICU or monitored bed): Hemodynamic instability, need for transfusion, unstable fracture pattern, associated injuries (urethral, bladder, vascular), polytrauma, inability to mobilize, need for surgical fixation [30-31]
• Admit (floor): Stable straddle fracture with inability to bear weight, elderly patients requiring pain management and PT evaluation, patients on anticoagulation requiring monitoring
• Observation: Hemodynamically stable patients with minimally displaced fractures who need serial hemoglobin checks and functional assessment
• Discharge (rare for true straddle fractures): Only if minimally displaced, hemodynamically stable, able to ambulate with assistive device, adequate pain control, reliable follow-up, and no GU injury
• Consult triggers: Orthopedic surgery (all pelvic ring injuries), urology (blood at meatus, hematuria, voiding difficulty), interventional radiology (active hemorrhage on CT), trauma surgery (polytrauma, hemodynamic instability) [30]

18. Follow Up / Return Precautions

• Orthopedic follow-up: Within 1–2 weeks with repeat imaging to assess alignment and healing
• Urology follow-up: Essential for all patients with urethral or bladder injury — timing of definitive urethroplasty typically 3–6 months post-injury [32]
• VTE prophylaxis duration: Continue for up to 4 weeks post-injury for high-risk patients; consider extended prophylaxis with aspirin or LMWH post-discharge [33]
• Return precautions: Instruct patients to return immediately for increasing pain, inability to urinate, blood in urine, fever, leg swelling, shortness of breath, lightheadedness/syncope, or worsening inability to bear weight
• Expected recovery: Stable fractures typically heal in 6–12 weeks with conservative management; elderly patients may have prolonged recovery and increased 90-day mortality (16%). Stress fractures in athletes require cessation of running until symptom-free [8][18]
• Long-term considerations: Monitor for chronic pelvic pain, sexual dysfunction, urethral stricture (in PFUI patients), and post-traumatic arthritis

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